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Fundamentals · chapter 7 · Vital Signs

Indicators of Physiologic Functioning

The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.

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Key points

  1. Vital sign changes

    Sometimes these changes are part of the body’s attempt to regulate itself and get back into balance; other times they are signals that the body is unable to properly regulate itself, and further intervention is required. Understanding these signs can help prevent a life-threatening emergency.

  2. Five vital signs

    The five vital signs are temperature (T), pulse (also known as heart rate [HR]), blood pressure (BP), respiratory rate (RR), and saturation of peripheral oxygen (SpO 2). These vital signs are interrelated; for example, an increase in respiratory rate often correlates with an increase in heart rate, while a decrease in oxygen saturation may correspond with a decrease in blood pressure.

  3. Pain as vital sign

    Pain is often regarded as the sixth vital sign, and changes in a patient’s pain can affect all five other vital signs. Thus, it is often assessed along with vital signs.

  4. Normal range variation

    Vital signs have established normal and abnormal ranges, but variations occur. Besides an individual’s personal baseline, vital sign parameters can also vary across the life span and change as a person gets older.

  5. Age-related norms

    What is considered normal for an infant or a toddler can be abnormal or problematic in an adult, and vice versa.

  6. Age and heart rate

    A resting heart rate of 120 bpm in a newborn is acceptable; however, a resting heart rate this fast is problematic in an adolescent or adult. Knowing these age-related variations is key for the nurse to recognize what heart rate is appropriate for their patient and identify the correct course of action if not appropriate.

  7. Assessment timing

    In general, healthcare facilities set their own guidelines as to when vital sign should be measured, and these guidelines depend on the acuity of the patients in the facility.

  8. Nurse reassessment

    In addition to assessing vital signs as per facility guidelines, the nurse is empowered to take vital signs when necessary. For instance, if a patient says they are short of breath and they appear pale and sweaty, or complain of a racing heart or a pounding headache, the nurse can recheck the patient’s vital signs on the spot.

  9. RN accountability

    Regardless of who takes the vital signs, the registered nurse is ultimately responsible for taking action should there be any issues.

  10. Temperature fluctuations

    Fluctuations occur within normothermia due to circadian rhythm, metabolism, and hormones. For instance, circadian rhythm refers to the body’s natural ability to lose heat in the extremities due to naturally occurring vasodilatation of the cutaneous vasculature during sleep-wake cycles.

  11. Hypothalamus response

    For example, if the body’s temperature is increasing, the hypothalamus will detect this change and increase blood flow to the body’s surface, which in turn activates the sweat glands, inducing perspiration. If the body’s temperature is decreasing, the hypothalamus will induce shivering to create more heat.

  12. Temperature extremes

    When the core body temperature is more than 105.8°F (41°C), hyperthermia occurs. When the core body temperature is less than 95°F (35°C), it is known as hypothermia.

  13. Pulse force

    Pulse force can range from absent to bounding. The volume of blood, the heart’s functioning, and the arteries’ elastic properties affect a person’s pulse force.

  14. Respiratory distress

    However, loud breathing, nasal flaring, or the use of accessory muscles in the neck, chest, or intercostal spaces indicate respiratory distress.

Terms to know

homeostasis
The process of self-regulation that bodies maintain through multiple, interdependent physiological processes is called homeostasis.
vital sign
The markers of physiological homeostasis are called vital sign, and they are essential in the analysis of monitoring patient progress.
normothermia
The targeted range for body temperature is referred to as normothermia.
thermoregulation
The body’s ability to maintain its temperature within normal ranges is termed thermoregulation.
pyrexia
A body temperature greater than 100.4°F (38°C) is called pyrexia, or fever (Cleveland Clinic, 2023).
pulse
A pulse is the palpable way to assess each time the heart beats, while heart rate is the number of times the heart beats in one minute; these two terms are often used interchangeably.
oxygen saturation
The measure of arterial oxyhemoglobin saturation (SpO 2) of arterial blood is called oxygen saturation.

Practice questions

Stuck on select-all-that-apply? How to take them one option at a time.

The graded version needs JavaScript. Every question is below anyway, with the answer and why.

Every question here, with the answer

  1. A hospitalized patient tells the nurse, “I feel short of breath.” The nurse notes the patient appears pale and sweaty. Which action should the nurse take?

    1. Wait until the facility’s next scheduled vital sign time.
    2. Recheck the patient’s vital signs immediately.
    3. Ask unlicensed assistive personnel to document the complaint only.
    4. Assess only the patient’s pain because pain is the sixth vital sign.

    Answer: Recheck the patient’s vital signs immediately.

    The section states that the nurse is empowered to take vital signs when a patient’s status changes. Shortness of breath with pallor and sweating is a change that should be correlated with vital sign measurements to guide next actions.

  2. The nurse is assessing respirations in an adult patient. Which findings indicate possible respiratory distress? Select all that apply.

    1. Nasal flaring
    2. Loud breathing
    3. Breathing that is relaxed and silent
    4. Use of accessory muscles in the neck, chest, or intercostal spaces
    5. A regular rhythm while the patient is awake

    Answer: Nasal flaring, Loud breathing, Use of accessory muscles in the neck, chest, or intercostal spaces

    The section identifies loud breathing, nasal flaring, and accessory muscle use as signs of respiratory distress. Relaxed, silent breathing and a regular rhythm in an awake adult are described as normal findings.

  3. The nurse is comparing pulse equality in a patient. Which assessment technique requires correction for safety?

    1. Palpating both carotid pulses at the same time
    2. Documenting pulse force using a four-point scale
    3. Assessing whether the pulse rhythm has equal intervals
    4. Palpating the right and left radial pulses at the same time

    Answer: Palpating both carotid pulses at the same time

    The section states that radial pulses may be compared on both sides at the same time. Carotid pulses should not be palpated simultaneously because doing so can decrease blood flow to the brain.

  4. The nurse is evaluating factors that may affect a patient’s temperature. Which factors should the nurse consider? Select all that apply.

    1. Pulse equality between the right and left radial pulses
    2. Age-related changes such as loss of insulating muscle mass or body fat
    3. Disease states involving immune system response
    4. Environmental changes, especially in older adults who thermoregulate less effectively
    5. Hormonal changes that affect hypothalamic sensitivity

    Answer: Age-related changes such as loss of insulating muscle mass or body fat, Disease states involving immune system response, Environmental changes, especially in older adults who thermoregulate less effectively, Hormonal changes that affect hypothalamic sensitivity

    The section lists age, environment, hormones, and disease states as factors affecting temperature. Pulse equality is part of pulse assessment, not a factor described as affecting body temperature.

  5. A nurse obtains an SpO2 reading of 93% for a patient. Based on this section, which response is most appropriate?

    1. Delay action unless the patient also has a fever.
    2. Recognize the value as normal and continue routine care.
    3. Assume the patient’s blood pressure must be decreased.
    4. Investigate the finding for possible hypoxia or technical error.

    Answer: Investigate the finding for possible hypoxia or technical error.

    The section states that normal SpO2 is 95 to 100 percent. A value less than 95 percent is abnormal and should be investigated for inadequate oxygenation or possible technical error.

  6. The nurse reviews heart rates for two resting patients: a newborn with a heart rate of 120 bpm and an adult with a heart rate of 120 bpm. Which interpretation is correct?

    1. Both findings are problematic because heart rate should decrease only in late adulthood.
    2. Both findings are acceptable because 120 bpm is normal across the life span.
    3. The adult’s heart rate is acceptable, but the newborn’s heart rate is problematic.
    4. The newborn’s heart rate is acceptable, but the adult’s heart rate is problematic.

    Answer: The newborn’s heart rate is acceptable, but the adult’s heart rate is problematic.

    The section emphasizes that normal vital signs vary by age. It specifically states that a resting heart rate of 120 bpm is acceptable in a newborn but problematic in an adolescent or adult.

Where every quote comes from

Section 7.1 Indicators of Physiologic Functioning of Fundamentals of Nursing by Christy Bowen, Lindsay Draper, Heather Moore, OpenStax, 2024. Read the whole section free at openstax.org.

The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.